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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: le" Y' G%��' D � 1 % f �.q �� S- Page of Facility Address: City: Ins p ction Qate: FA #: PR M Program Element: �Z �5d Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers`*. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: TA#: D 1 Product Type: Total Capacity: �' / �7 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) B Containers (2821) #of Containers: TA#: &,6 e-(3,z)a 2 Total Capacity: i � '9 gallons Product Type: Alrf"rr 4, �J (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ^� Z0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: oo Reviewed Date: By Initial: Entered Date: By Initial: -Z *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.( 1 ' **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08